Over the course of this chapter, we have attempted to present a focused approach to the evaluation of the athlete's shoulder that begins with an understanding of the patient's chief complaint and, based on this, immediately forms a differential diagnosis. The accuracy of this differential is enhanced by asking the right questions in the history such as onset, character, duration, clinical course, degree of disability, and response to clinical intervention. This differential-directed approach then guides the remainder of the encounter.
The physical examination of the overhead and throwing athlete remains an even more challenging art. However, with knowledge of various tests and techniques, the examiner can often narrow its focus. The examination should be organized and comprehensive, but with expectations for findings directed by the differential ("going for the money"). Finally, when possible, and especially when pain is a chief complaint, we are liberal in our use of local anesthetic to temporarily and completely relieve the patient's chief complaint as an aid to narrowing the diagnosis.
The advantage of the differential-directed approach is that it establishes a suspected diagnosis at the beginning of the encounter and guides the examiner as to what to look for during the examination. When one elicits expected positive findings, one's suspicions of the diagnosis are strengthened. However, even when the examiner is surprised by unexpected findings, it will redirect him or her toward another diagnosis that is also in the differential.
Formulating a differential at the beginning of the encounter, however, does have its risks. One must be careful not to be convinced too quickly, as overconfidence will lead to a biased interpretation of the physical examination findings and can result in a misdiagnosis. In addition, the quality of the differential and the skill of validating it depend largely on the examiner's knowledge of shoulder pathology and the various forms in which it presents. We have attempted to describe the process of this focused approach and hope that by formulating a short list of diagnoses early in the encounter, the examiner will be more directed, efficient, and accurate in the approach to the athlete's shoulder.
7. Calis M, Akgun K, Birtane M, et al: Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis 2000;59:44-47.
8. MacDonald PB, Clark P, Sutherland K: An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg 2000;9:299-301.
9. Boublik M, Silliman JF: History and physical examination. In Hawkins RJ, Misamore GW (eds): Shoulder Injuries in the Athlete. New York, Churchill Livingstone, 1996, pp 9-22.
10. Yocum LA: Assessing the shoulder. History, physical examination, differential diagnosis, and special tests used. Clin Sports Med 1983;2: 281-289.
11. Itoi E, Kido T, Sano A, et al: Which is more useful, the "full can test" or the "empty can test," in detecting the torn supraspinatus tendon? Am J Sports Med 1999;27:65-68.
12. Gerber C, Krushell RJ: Isolated rupture of the tendon of the sub-
scapularis muscle. Clinical features in 16 cases. J Bone Joint Surg (Am) 1991;73:389-394.
13. Tokish JM, Decker M, Ellis H, et al: The belly press test for the physical examination of the subscapularis muscle: Electromyographic validation and comparison to the lift-off test. Paper presented at the American Shoulder and Elbow Surgeons 3rd Biennial Open Meeting, 2002, Orlando, FL.
14. Hertel R, Ballmer FT, Lombert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313.
15. Codman EA: The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston, Thomas Todd, 1934.
16. Wolf EM, Agrawal V: Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears. J Shoulder Elbow Surg 2001; 10:470473.
17. Petersson CJ: The acromioclavicular joint in rheumatoid arthritis. Clin Orthop 1987;223:86-93.
18. O'Brien SJ, Pagnani MJ, Fealy S, et al: The active compression test: A new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med 1998;26:610-613.
19. Bennett WF: Specificity of the Speed's test: Arthroscopic technique for evaluation the biceps tendon at the level of the bicipital groove. Arthroscopy 1998;14:789-796.
20. Matsen FA, Kirby R: Office evaluation and management of shoulder pain. Orthop Clin North Am 1982;13:453-475.
21. Snyder SJ, Karzel RP, Del Pizzo W et al: SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279.
22. Berg EE, Ciullo JV: A clinical test for superior glenoid labral or 'SLAP' lesions. Clin J Sport Med 1998;8:121-123.
23. Kim SH, Ha KI, Ahn JH, et al: Biceps load test II: A clinical test for SLAP lesions of the shoulder. Arthroscopy 2001;17:160-164.
24. Kibler WB: Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy 1995; 11: 296-300.
25. Dines DM, Warren RF, Inglis AE, et al: The coracoid impingement syndrome. J Bone Joint Surg Br 1990;72:314-316.
26. Paley KJ, Jobe FW Pink MM, et al: Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16:35-40.
27. Tong HC, Haig AJ, Yamakawa K: The Spurling test and cervical radiculopathy. Spine 2002;15:156-159.
28. Porter P, Fernandez GN: Stretch-induced spinal accessory nerve palsy: A case report. J Shoulder Elbow Surg 2001;10:92-93.
29. Post M, Mayer J: Suprascapular nerve entrapment: Diagnosis and treatment. Clin Orthop 1987;223:125-136.
30. Ringel SP, Treihaft M, Carry M, et al: Suprascapular neuropathy in pitchers. Am J Sports Med 1990;18:80-86.
31. Rowe CR (ed): The Shoulder. New York, Churchill Livingstone, 1988, p 419.
32. Zaslav KR: Internal rotation resistance strength test: A new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg 2001;10:23-27.
33. Partington PF, Broome GH: Diagnostic injection around the shoulder: Hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 1998;7:147-150.
34. Matsen FA, Thomas SC, Rockwood CA, Wirth MA: Glenohumeral instability. In Rockwood CA, Matsen FA (eds): The Shoulder, 2nd ed. Philadelphia, WB Saunders, 1998, pp 611-754.
35. Hovis WD, Dean MT, Mallon WJ, Hawkins RJ: Posterior instability of the shoulder with secondary impingement in elite golfers. Am J Sports Med 2002;30:886-890.
36. Netter FH: The CIBA Collection of Medical Illustrations: Muscu-loskeletal System Part I: Anatomy, Physiology and Metabolic Disorders. Ciba-Geigy Corporation, 1991, p 29.
37. Fielding JW Francis WR, Hensinger RN: The cervical and thoracic spine. In Cruess RJ, Rennie WRJ (eds): Adult Orthopaedics, vol 2. New York, Churchill Livingstone, 1984, pp 747-841.
38. Feretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
39. Bryan WJ, Wild JJ: Isolated infraspinatus atrophy: A common cause of posterior shoulder pain and weakness in the throwing athlete. Am J Sports Med 1989;17:130-131.
40. Lauland T, Fedders O, Sgaard I, Kornum M: Suprascapular nerve compression syndrome. Surg Neurol 1984;22:308-310.
41. Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11: 600-604.
42. Hershman EB, Wilbourn AJ, Bergfeld JA: Acute brachial neuropathy in athletes. Am J Sports Med 1989;17:655-659.
43. DiFelice GS, Paletta GA, Phillips BB, Wright RW: Effort thrombosis in the elite throwing athlete. Am J Sports Med 2002;30:708-712.
44. Duralde XA, Bigliani LU: Neurologic disorders. In Hawkins RJ, Mis-amore GW (eds): Shoulder Injuries in the Athlete. New York, Churchill Livingstone, 1996, pp 243-265.
45. Mitsunga MM, Nakano K: High radial nerve palsy following strenuous muscular activity. Clin Orthop 1982;98:39-42.
46. Priest JD: The shoulder of the tennis player. Clin Sports Med 1988;7:387-402.
47. Wright IS: The neurovascular syndrome produced by hyperabduction of the arm. Am Heart J 1945;29:1-4.
48. Murray TA, Cook TD, Werner SL, et al: The effects of extended play on professional pitchers. Am J Sports Med 2001;29:137-142.
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